There are several challenges associated with autoimmune and immune-mediated diseases and conditions, including but not limited to, struggling to obtain an accurate diagnosis, feeling misunderstood by peers, and having difficulties navigating health care, insurance, and out-of-pocket costs. The disease burden of these complex and chronic conditions is arguably greater for women, who often serve as caregivers for children, partners, and parents who may suffer from chronic conditions.
Since no cure exists for autoimmune diseases, treatments are focused on managing symptoms and slowing the progression and impacts of the disease across the lifespan. For this reason, finding and maintaining an effective medication regimen in a timely manner is critical. When insurance coverage policies delay or prevent access to effective treatment, women can be left vulnerable to serious, irreversible health complications as well as financial and emotional challenges. Autoimmune Association President and CEO Molly Murray, in an interview with the National Pharmaceutical Council (NPC), shared how coverage can factor into individuals’ treatment challenges:
“Unfortunately, people confront coverage barriers after diagnosis and identifying the right treatment regimen for their condition. People face high deductibles that renew at the start of the year. Other out-of-pockets costs include coinsurance instead of fixed copayments for medications, where patients have to pay a percentage of the cost of their medicines instead of a fixed amount. That’s assuming that patients are able to access those medicines and aren’t subject to tiered formularies and ‘fail first’ policies, which require them to try and fail on multiple medicines before accessing the one their doctor recommends. Every barrier to coverage means delays, and for people with autoimmune diseases, delays mean poorer health outcomes, greater disability, and health losses that cannot be regained.”
– Molly Murray, President and CEO, Autoimmune Association, NPC Interview, March 24, 2022
Today, some of the coverage and access policies that can most affect women with autoimmune diseases and conditions, such as step therapy, are becoming increasingly common within health plans. According to a 2018 article in Health Affairs, showed that step therapy, also known as step edits, was the most common type of restriction in health plans and used in nearly 75 percent of coverage decisions. Within the plans that utilized step therapy, the study’s authors found that 66 percent of these restrictions required one step, 20 percent required two or more steps, and 14 percent required three or more steps before coverage. Each of these “steps” represents valuable time lost for autoimmune patients.
To raise awareness about the challenges related to coverage policies, the Society for Women’s Health Research (SWHR) released the policy brief, “Issues Affecting Health Care Coverage and Access for Women with Autoimmune Diseases and Conditions.” The brief discusses how certain policies, including prior authorization, step therapy, non-medical switching, and co-pay accumulators, can negatively affect women with autoimmune diseases and conditions and provides recommendations on minor changes for these policies that could meaningfully improve health and quality-of-life outcomes.
This brief is one of a four briefs on autoimmune policy issues. Stay tuned for future briefs!
Support for this educational program has been provided by Horizon Therapeutics. SWHR maintains independence and editorial control over program development, content, and work products.